Milrinone drip how to declot noncontinuous ports

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Question: patient has a triple lumpen pic with continuous milrinone drip. The line running milrinone is patent but other lumens are sluggish/occluded. Can you leave milrinone drip running while declotting other lumens with cathflo?

We have patients use it at home even

Us too. Not sure why the angst.

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Specializes in Critical Care and ED.

From IV-Therapy.net:

"If there is incompatiblity or no information can be found, I would stop the infusing drug during the declotting procedure. You do not want these drugs mixing at the catheter tip and forming a precipitate which could cause particulate matter to be trapped in the lungs or further occlude the open lumen or both. If patient stability during the procedure is an issue, you would have to find some other means for infusion such as a peripheral catheter. It can precipitate with or without a staggered lumen exit site. The distance between each lumen may not be enough to prevent contact"

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From IV-Therapy.net:

"If there is incompatiblity or no information can be found, I would stop the infusing drug during the declotting procedure. You do not want these drugs mixing at the catheter tip and forming a precipitate which could cause particulate matter to be trapped in the lungs or further occlude the open lumen or both. If patient stability during the procedure is an issue, you would have to find some other means for infusion such as a peripheral catheter. It can precipitate with or without a staggered lumen exit site. The distance between each lumen may not be enough to prevent contact"

Point well-taken but what about your stance on the safety of this drug? You seem pretty firm that this is an extremely risky drug, even at catheter de-clotting dosage, and that it should never be given outpatient because of the high potential for catastrophic adverse effects. I'm interested in hearing what you've experienced that has led you to have such an impassioned opinion. I truly am not being snarky as this is my current area of expertise and I'm open to hearing new thoughts on the subject.

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Specializes in Critical Care and ED.
Point well-taken but what about your stance on the safety of this drug? You seem pretty firm that this is an extremely risky drug, even at catheter de-clotting dosage, and that it should never be given outpatient because of the high potential for catastrophic adverse effects. I'm interested in hearing what you've experienced that has led you to have such an impassioned opinion. I truly am not being snarky as this is my current area of expertise and I'm open to hearing new thoughts on the subject.

It's from my years spent as an acute dialysis nurse and in cardiac critical care where my patients were very unstable and had the potential to bleed. We always had it drummed into us to use cathflo with the ultimate respect and caution. I have had incidences where a patient came in with a fistula or graft that didn't work and had a cath placed that also didn't work so we'd stick their fistula first and then access the line and then have to use cathflo and then they'd bleed from their fistula like crazy. Different population I know, but it's always made me use caution. Also, with patients in DIC or who bled post CABG and were coagulopathic. It makes me nervous. Probably less so with outpatients who were more stable but I would use the same caution if it were me.

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Specializes in Oncology.
From IV-Therapy.net:

"If there is incompatiblity or no information can be found, I would stop the infusing drug during the declotting procedure. You do not want these drugs mixing at the catheter tip and forming a precipitate which could cause particulate matter to be trapped in the lungs or further occlude the open lumen or both. If patient stability during the procedure is an issue, you would have to find some other means for infusion such as a peripheral catheter. It can precipitate with or without a staggered lumen exit site. The distance between each lumen may not be enough to prevent contact"

I guess if you're able to take this caution, better safe than sorry.

BUT the whole point of multilumen CVLs is to be able simultaneously infuse incompatible drugs.

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It's from my years spent as an acute dialysis nurse and in cardiac critical care where my patients were very unstable and had the potential to bleed. We always had it drummed into us to use cathflo with the ultimate respect and caution. I have had incidences where a patient came in with a fistula or graft that didn't work and had a cath placed that also didn't work so we'd stick their fistula first and then access the line and then have to use cathflo and then they'd bleed from their fistula like crazy. Different population I know, but it's always made me use caution. Also, with patients in DIC or who bled post CABG and were coagulopathic. It makes me nervous. Probably less so with outpatients who were more stable but I would use the same caution if it were me.

Well, it's not like I don't "respect" it. Heck, I respect aspirin but you're right, very different patient population. The question I have though is are you sure the bleeding fistulas were directly related to the Cathflo or in other patients to their coagulopathy. These should have been reported to the company for further study. Also, why was it given systemically? I guess I find it interesting since it has such a short half life, is primarily active on the fribrin in clots and even when given as a bolus did not reach a blood concentration even close to the level needed to cause catastrophic bleeding. Very interesting information.

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Specializes in Critical Care.
No, I would not do that. If any of the cathflo gets into the patient you have a potentially catastrophic event on your hands and you will be liable. Cathflo should only be used on lines that are not currently running a medication. Why take the risk?

It's a HUGE issue. This medication has life-threatening risks and is only given systemically in an emergency...basically in active MI. It's a tissue plasminogen activator that is higher up in the clotting cascade than a platelet inhibitor. There is also no antidote. Don't do it! If the patient has an active med running through that line do not instill it. Does she become unstable when the milrinone is held?

A few things; I think you missed that the clotted lumen is a different lumen from the one that the milrinone is infusing through, tPA is firmly established as safe for use in declotting lines, by far the most common use of tPA is to declot lines, followed by use strokes. There is no reason to stop a medication in one lumen to declot with tPA in another lumen. Milrinone should not be held for the time it takes for tPA to dwell, that is far more dangerous than declotting with tPA.

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I guess if you're able to take this caution, better safe than sorry.

BUT the whole point of multilumen CVLs is to be able simultaneously infuse incompatible drugs.

Yes. According to the above comment above from IV-Therapy.net, multi-lumen CVADs shouldn't be trusted to serve one of their main uses.

Interesting discussion. If would be nice to read about our specific compatibility questions somewhere so that this didn't seem like merely anecdotal evidence. But, from day one I was taught that that minute amount of tPA that could potentially enter the bloodstream in pharmacologically insignificant amounts with ~2L/min blood flow through the SVC meant this was not a significant concern (both the tPA itself and the idea that it might be incompatible with something infusing in a separate lumen). I tried a lit search but am left with only my anecdote except for this article which concerns antimicrobial lock solutions (instilling antibiotics into a catheter that is a likely source of infection when removal isn't desirable) and is sprinkled with comments about combining the various studied abx with things like tPA and heparin amongst others in attempts to help prevent occlusion of the line.

Bookstaver, P. B., Rokas, K. E., Norris, L. B., Edwards, J. M., & Sherertz, R. J. (2013, December 15). Stability and compatibility of antimicrobial lock solutions. American Journal of Health-System Pharmacy, 70, 2185-2198. Retrieved from https://www.sefh.es/fichadjuntos/Antimicrobiallocksolutions.AJHP2014.pdf

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Specializes in Critical Care.
I guess if you're able to take this caution, better safe than sorry.

BUT the whole point of multilumen CVLs is to be able simultaneously infuse incompatible drugs.

The quote comes from a somewhat controversial "expert" who's views on a variety of practices are either ignorant of basic scientific principles, or completely contradictory to them. She has suggested in the past in addition to this post that incompatible medications should not be infused even through completely separate lumens, despite this being a practice that is well established to be safe and appropriate. when asked for supporting evidence or even a general scientific basis for this, she hasn't been able to offer anything.

The potential for precipitate formation and drug-drug inhibition of effects can be calculated using the rate of flow at the point of exit and the pH of the two drugs and other measurable characteristics, and there is no basis for not infusing any two medications through separate lumens.

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The quote comes from a somewhat controversial "expert" who's views on a variety of practices are either ignorant of basic scientific principles, or completely contradictory to them. She has suggested in the past in addition to this post that incompatible medications should not be infused even through completely separate lumens, despite this being a practice that is well established to be safe and appropriate. when asked for supporting evidence or even a general scientific basis for this, she hasn't been able to offer anything.

The potential for precipitate formation and drug-drug inhibition of effects can be calculated using the rate of flow at the point of exit and the pH of the two drugs and other measurable characteristics, and there is no basis for not infusing any two medications through separate lumens.

Just to clarify I'm pretty sure Muno is not referring to Blondy or Rocknurse but to the owner of the IV-therapy.net site. It took me a minute to realize this. Some of her stuff is head-scratching.

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It's from my years spent as an acute dialysis nurse and in cardiac critical care where my patients were very unstable and had the potential to bleed. We always had it drummed into us to use cathflo with the ultimate respect and caution. I have had incidences where a patient came in with a fistula or graft that didn't work and had a cath placed that also didn't work so we'd stick their fistula first and then access the line and then have to use cathflo and then they'd bleed from their fistula like crazy. Different population I know, but it's always made me use caution. Also, with patients in DIC or who bled post CABG and were coagulopathic. It makes me nervous. Probably less so with outpatients who were more stable but I would use the same caution if it were me.

I have an IV drug guide that says Cathflo Activase should be used cautiously for patients who have active internal bleeding or have problems that can cause bleeding, for example kidney problems, or who would be at risk for serious problems if bleeding happens, particularly elderly patients. It says the action to take if serious bleeding happens.

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Years ago a nurse on the IV team showed me a trick about how to unclog an occluded port without cathflo. I've used it for years and it works like a charm.

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